Basic Information
Provider Information | |||||||||
NPI: | 1043750995 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STRAWHACKER | ||||||||
FirstName: | EMILY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MDT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 813 FLORIDA ST SW | ||||||||
Address2: |   | ||||||||
City: | LONSDALE | ||||||||
State: | MN | ||||||||
PostalCode: | 550468601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9524579313 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 309 HOLLY LN | ||||||||
Address2: |   | ||||||||
City: | MANKATO | ||||||||
State: | MN | ||||||||
PostalCode: | 560015422 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5073882120 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/26/2017 | ||||||||
LastUpdateDate: | 02/26/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 125J00000X | DT81 | MN | Y |   | Dental Providers | Dental Therapist |   |
No ID Information.